Video gaming as an add-on intervention in emotion regulation therapy among adolescents with internalizing disorders: a preliminary study.

Research suggest that incorporating adaptive emotion regulation strategies into
effective treatments of internalizing problems is important, needs more
attention and can increase efficacy of the treatment (Braet & Bögels, 2014).
This seems even more important for adolescents with internalizing
problems.Cognitive behavioral therapy (CBT) is the most used and evidence-based
approach for therapy of adolescents with symptoms of anxiety and depression
(Hannesdottir & Ollendick, 2007), but there are limitations; (1) children and
adolescents can be inconsistent in their motivation to change and may find the
sessions boring, and (2) there is a large gap between what they actually learn
from the CBT and what they practice in everyday live (Kazdin & Blase, 2011).
Therefore, other models of treatment are being developed to deliver healthcare
that is more attractive for younger patients and make a sound translation to
their daily life. One of these novel approaches is gamification (Kazdin &
Rabitt, 2013). Video games hold immense potential to teach new forms of thought
and behavior, because youth is already motivated and used to play videogames
(Granic, Lobel & Engels, 2014). Therefore, serious games can possibly support
the learning of new techniques if traditional CBT methods are too boring.
They provide knowledge as well as elements of play and increasing engagement
(Girard, Ecalle & Magnan, 2012). Serious games also provide opportunities to
practice new regulatory skills until they are automatized and form new neural
patterns for generalization (Schuurmans et al., 2015). Another relevant
advantage of a serious game is that it costs less time then a regular CBT and
this may have an impact on the number of drop-outs. Schoneveld and colleagues (
2018) also suggest that it is an advantage when youth has access to the serious
game at home.
Earlier research on serious gaming for improvement of ERS has focused mostly on
youth with externalizing psychopathology and anxiety in a residential setting,
but emotion regulation problems also occurs within youth with internalizing
psychopathology. The present study aims to test the feasibility of a serious
game for emotion regulation problems (Dojo) and will asses the initial
effectiveness of the serious game as add on to treatment as usual (TAU) among
youth with internalizing psychopathology in an ambulatory setting, more
specific adolescents with anxiety or depression.

We hypothesize that adolescents who play a serious game as add on to the
regular CBT stay more interested to play the game, are satisfied with the game,
do more homework and are able to apply the learned strategies in real-life. We
expect little negative effects. We also expect an improvement in their adaptive
emotion regulation strategies and a decrease in their maladaptive emotion
regulation strategies. Finally, we hypothesize a decrease in their
anxiety/depression symptoms.

This study assesses the feasibility of adding a serious game to treatment as
usual (CBT) in ameliorating emotion regulation skills.
1) When (number of sessions) are adolescents losing their interest in the game?
Are they satisfied with the game in general?
2) What is the duration and frequency that adolescents spend on their homework
(play the game)?
3) Are there negative effects (on their homework/school, social contacts and
hobbies)?
4) Is there a decrease in the use of maladaptive emotion regulation strategies?
5) Is there an improvement in the use of adaptive emotion regulation
strategies?
6) Is there a decrease in the anxiety/depression symptoms?

This study is an open clinical trial. Emotion regulation strategies are
investigated with self-report questionnaires (quantitative data) pre-
post-treatment and during follow up after 3 and 6 months. The amount/duration
of homework, interest in the game and satisfaction are being measured with a
short questionnaire (qualitative data) and personal game data, such as time and
duration they play the game . Negative effects (on their homework/school,
social contacts and hobbies) are being measured with questionnaires
(quantitative and qualitative data).

Burden:
Emotion regulation strategies are investigated with self-report questionnaires
pre- post-treatment and during follow up after 3 and 6 months (1: 55-60 min, 2:
55-60 min, 3 & 4: 45 min).
Playing the serious game: minimum of 20 minutes a day in 12 weeks (total:
minimum of 1680 minutes).

Possible benefits: improvement of emotion regulation strategies.

Possible risks: little risk of development of a game-addiction.